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Blood Transfusion Assignment
Transfusion Related Acute Lung Injury ( TRALI) Scenario Name: Transfusion Related Acute Lung Injury (TRALI) Submitted by: GROUP I Simulator Used: SimMan Case Description: Patient is a 76 yr old female who was admitted in the evening through the Emergency Room with a left hip fracture. Patient Information Patient is a 76 year old female who fell when she tripped over her cat and now has a left hip fracture. History of Present Illness: Patient was brought in via ambulance with a left hip fracture. ER Labs: UA, CBC, PT & INR, PTT, BMP, Type and Cross Match for 2 units Packed Red Blood Cells for surgery the following day and 3 units of Fresh Frozen Plasma. (Order reads to give 3 units FFP ASAP and Type and Cross for 2 U PRBC’s for surgery) Past Medical History: Atrial Fibrillation History of CVD She has no known allergies She is not a smoker. Social History: Patient has been living independently at home with minimal assistance from her family. Her husband is deceased. She has three living children, a daughter and two sons. Current Medications: Coumadin (Warfarin) 5 mg QD Zocor (Simvastatin) 40 mg QD Daily Multi- vitamin QD Morphine Sulfate 2mg IV Q 2- 4 hr. PRN Scenario – Patient is scheduled for hip surgery tomorrow. She is receiving the first of 3 units of FFP ordered to reverse the Coumadin effects prior to the surgery. She has received approximately 100 ml of the first unit of FFP when the respiratory symptoms begin. Her vital signs have changed significantly post transfusion. Prerequisite Knowledge: Types of possible transfusion reactions to include ABO incompatibility, infection, TRALI, Transfusion-associated circulatory overload (TACO ) per basic nursing book Equipment: #SimManTM in hospital gown #22 g IV access (Saline locked) #Pulse Oximeter #02/NC available #BP cuff #Thermometer #Patient chart with order from physician for RBC’s and platelets #Signed consent for blood transfusion #Lab results from ER admit (CBC, PT& INR, PTT, Cross match for 2 U PRBCs and 3 U Fresh Frozen Plasma (FFP), Basis Metabolic Panel) #100 ml and 1 Liter bags of Normal Saline, D5NS available in room #Stethoscope #IV pole #IV Pump #Patient Identification Band #Cross Match Wrist Band #Simulated FFP #Blood Tubing for both RBC’s and FFP #Phone #Foley Catheter in place #Wall Clock Room Set up: Patient chart with ER admit orders for blood transfusion of Fresh Frozen Plasma Lab results from ER workup; CBC (includes hemoglobin and hematocrit, platelet count, white blood cell count.), PT& INR showing therapeutic level for patient with A Fib, BMP with Normal value results. XRAY report showing Left hip fracture Personnel needed: RN CNA Charge Nurse Physician by phone Family member Basic scenario tips: Confirm identity of patient and blood product with RN. Check for signed consent form. Monitor closely first 5 minutes, recheck VS @15 minutes and 30 minutes and at the completion of run (usually not more than 45 minutes) Continuous monitor of pulse oximetry (ideal), monitor vital signs (Pulse, Respirations, BP, Temp.) throughout the process of patient receiving the blood products or platelets. Common pitfalls: . Not watching vitals signs for small changes. Failure to apply O2 and turn on. Failure to stop transfusion when vital signs change. Notify MD of reaction and receive further orders. Target Audience: 2nd year nursing students (ADN), 4th yr (BSN), Med/Surg, ICU, ER, OR staff Estimated Time: 15- 30 min. Learning Objectives: At the end of the module the student will be able to: 1) Recognize the signs and symptoms of a transfusion reaction. 2) Utilize nursing interventions during the blood transfusion. 3) Implement professional and therapeutic communication during interactions with members of the health care team (patient, family, doctor, nurse) Scenario Event Checklist: To include: events, minimal behaviors expected, cues/prompts, questions, teaching points Expected behaviors: '' 1) Identification of transfusion reaction when signs of reaction occur.(i.e. change in VS or difficulty breathing) 2) Stopping of transfusion when reaction recognized and applying 02. 3) Notify physician of change in VS (using SBAR) during transfusion and anticipate further orders. ''Cues '' May need patient to complain of difficulty in breathing by saying “I can’t breathe very well” or patient is gasping for breath. Family growing very concerned about mother not being able to breath. ''Prompts - '' Beeping of pulse ox when O2 sat decreases below desired settings (if being used in continuous mode) Pulse Oximeter is optional equipment. Beeping of Dynamap if alarm set for hypotensive rates, CNA to take vitals prior to beginning transfusion and at required intervals during the transfusion. CNA notices change from first readings and reports to the RN. Implementation of Scenario including simulator settings based on progression over time Goals SimMan TM settings Debriefing - ''Critical points to cover in debriefing: '' Did the student stop the transfusion when VS changed significantly? Did the student report the event to the medical provider promptly? Did the student complete a transfusion reaction workup? (if that was on objective) To students involved: How did you feel during the scenario? '' To student observers: What went well? To students involved: What would you do differently? To student observers if any: What would you do differently? Discuss any events on checklist that were done incorrectly or missed. Discussion topics: TRALI vs. TACO Other possible transfusion reactions such as ABO incompatibility, Bacterial contamination Why is Lasix not indicated in TRALI? Roles: RN assigned to patient: Patient chart available Can ask for help from other staff Charge Nurse (as resource) Serve as resource for primary RN Able to make suggestions to RN w/o being asked CNA Can do delegated tasks Can suggest task within their scope of practice Family Members Asks questions about surgery Why receiving transfusion of FFP Concerned about pain level Safety of blood (HIV or AIDS, Hepatitis?) Assist in concern for family member when she can’t breath. Dr. Sim – Nurse to report VS and status of patient Did nurse stop transfusion? If not have them do right away. Ask nurse to work up as transfusion reaction and forward to blood bank. Order STAT chest XRAY Interventions/tasks student should demonstrate Looks for critical information on chart: PT with INR, Hgb/Hct, BMP Signed consent for blood products (?) may or may not perform if blood product already hanging not needed as check would have been done. Physical assessment of manikin (including VS, pain level, heart and lung sounds, bowel sounds, level of consciousness, patent IV site) Review orders from MD Notes orders for IV fluids, medications, diet, order for 3 Units of FFP to be given ASAP Ask/check for information in history of prior transfusion reactions (possible higher level of thinking) Interacts with patient and family members appropriately Interacts with ancillary personnel and MD in professional manner Reassessment: Student completes assessment to include review of VS, IV site prior to initiating FFP transfusion. Identifies change in patient status (transfusion reaction) Applies 02/NC and turns on O2Student notifies appropriate team members as resources. References ABO compatibility and transfusion reactions per required reading of education facility. Policy/procedures for the hanging of blood products. Bishop-Hendler, C. (2008). A perfect match; Preventing blood incompatibility errors. Nursing Spectrum, Northwest Edition, (6) 24-29. Hendler, C. (2008). A perfect match: Preventing blood incompatibility errors. Nursing Spectrum, Northwest Edition (6), 24-28. Spader, C. (2008). The bad and ugly of transfusions. Critical Care, Spring Specialty Guide, '' '' 62 - 64. Simmons, P. (2003) A primer for nurses who administer blood products. MedSurg Nursing. ''(6)''12, 3, 184-191. COLA (2010) Transfusion Related Acute Lung Injury Case Studies, (AABB) American Association of Blood Banks, Retrieved November 12. 2013 from http://www.coal.org/product.html?ProductID=346 Blood Transfusion, Minnesota Simulation Library (2006). Metro Alliance Nursing Simulation Task Force, July, 2006, Century College Retrieved November 12, 2013 from http://mnsiblib.tela.com/forum/index.ph